Retreat at Wellmore of Lexington
200 Wellmore Drive, Lexington, SC 29072 · For profit - Limited Liability company · 60 certified beds · (803) 520-1200 Medicare only — no Medicaid
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,153 in federal fines (most recent 2025-05-22)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.9% | 11.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.5% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.5% | 1.3% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 3.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.0% | 3.2% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 33.3% | 21.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 89.3% | 90.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.4% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.3% | 16.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.0% | 15.3% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.6% | 78.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.3% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.7% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.43 | 2.04 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.61 | 1.84 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 307 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 165 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.64 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.8%CMS range 40.3–53.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.9–13.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 60.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 62.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 38.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 61.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 85.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.4%CMS range 3.1–8.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 45.7 residents a day — about 76% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.91 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.67 hrs/resident/day on weekends vs 5.17 on weekdays — 10% thinner on weekends. RN hours go from 0.85 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Immediate jeopardy · J2025-05-22 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review and interview, the facility failed to ensure Resident (R)43 was free from significant medication error. Specifically, the facility failed to ensure that R43 received the correct medication order for Bupropion/Wellbutrin, which led to the resident being hospitalized . On 05/21/25 at 1:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 03/04/25. The IJ was related to 42 CFR 483.25 - Pharmacy Services. On 05/22/25 the facility provided an acceptable IJ Removal Plan. On 05/22/25 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 03/13/25. An extended survey was conducted in conjunction with the Recertification and Complaint Survey, for non-compliance at F760, constituting substandard quality of care. Findings include: Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the refrigerator and dry storage were labeled and discarded after the manufacturer's expiration date. Findings Include: Review of the facility's policy titled, Food Receiving and Storage, with a revised date of November 2022, reveals, Food shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated. Such foods are rotated using a first in-first out system. Refrigerated/Frozen Storage: 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During an initial tour observation on 01/29/24 at 12:24PM, in the walk-in refrigerator and dry storage area revealed: 1. One unopened five-pound bag of Mozzarella cheese labeled with a received date of 12/29/23, had a manufactured expiration date of 11/29/23, which also contained mold. 2. A blue bucket that did not contain any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observations, interviews, and record review, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to ensure 2 of 2 residents (R) 34 and R195's, continuous positive airway pressure (CPAP), were properly cleaned and stored after each use. This failure has the potential to cause respiratory and other communicable infections/complications. Findings Include: Review of the facility policy titled, CPAP/BiPAP Support, with a revised date of March 2015, states, 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. Review of R34's face sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to hypertension and obstructive sleep apnea. Review of R34's treatment orders revealed an order dated 01/11/24, which indicated, continuous positive airway…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-31 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observations, interviews, and manufacturer package inserts, the facility failed to maintain clean medication carts for 2 of 7 med carts and failed to prevent expired and/or improper storage of medications in 2 of 4 med rooms. Findings include: Review of the facility's policy titled, Storage of Medications, revised [DATE], stated that the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of the facility's policy titled, Medication Labeling and Storage, dated February 2023, stated that if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. On [DATE] at approximately 1:08 PM inspection of the 100-hall south medication cart revealed sticky substances on bottles of Pro-stat and bottom of third (3rd) drawer on left side of cart. On [DATE] at approximately 1:13 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-31 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility policy, observation, and interview, the facility failed to establish and maintain an infection prevention and control program to prevent the development and transmission of communicable disease and infections related to influenza for one of one, Resident (R)1. Findings include: Review of the facility policy titled Influenza, Prevention and Control of Seasonal, revised March 2022 states, This facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. Influenza Control, 6. Visits to residents on precautions for influenza are scheduled and controlled to allow for: a. screening visitors for symptoms of acute respiratory illness before entering the facility; and b. providing instruction before visitors enter residents' rooms, on hand hygiene, limiting surfaces touched, and use of personal protective equipment (PPE) while in resident's room. Infection Precautions: 1. Contact and droplet precautions are implemented for residents with suspected or confirmed influenza for seven (7) days after illness onset or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-02-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to ensure foods stored in the kitchen were labeled, dated, and not expired. These failures had the potential to increase the prevalence and spread of foodborne illness and infection to all facility residents. Findings include: Review of the Pye [NAME] Quality Control Checklist for Cleaning of Exhaust System dated 11/18/20, 3/3/21, 8/24/21, and a 01/31/22 email and on 1/17/22, cleaning was canceled and rescheduled for 3/28/22. During a review of the facility's policy and procedures the following was revealed: The Refrigerators and Freezers policy stated .#7 All food shall be appropriately dated to ensure proper rotation by expiration dates . Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage . Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-02-03 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, review of the manufacturer's guidelines for medication use, and review of the facility's policy and procedures, the facility failed to ensure that three of five residents (Resident (R) R30, R41, and R42) reviewed for unnecessary medication use did not receive psychoactive medications without an appropriate assessment and indication for use, monitoring of adverse effects, attempting gradual dose reductions when appropriate, reducing or discontinuing as needed psychotropics past the 14 day criteria, identifying and routinely monitoring specific target behaviors, and developing and implementing resident specific non-pharmacological interventions. This deficient practice had the potential for serious harm and/or death for all residents who reside in the facility. Findings include: Review of the facility's policy dated April 2018 titled, Medication Utilization and Prescribing- Clinical Protocol stated Assessment and Recognition:2. As part of the overall review,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-03 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews and review of the facility policy titled, Advance Directives, the facility failed to ensure Resident (R)19 and R42 were afforded the right to formulate an advance directive for 2 of 4 residents reviewed for Advance Directives. Findings Include: The facility admitted R19 with diagnoses including, but not limited to, bipolar disorder, schizoaffective disorder, anxiety and legal blindness. Review on [DATE] at 1:22 PM of the medical record for R19 revealed no documentation to ensure R19 was afforded the right to formulate an Advance Directive. Further review on [DATE] at 1:25 PM of the medical record for R19 revealed no assessments and signatures of 2 physician's indicating that R19 was not able to make her own healthcare decisions. During an interview on [DATE] at 3:35 PM with the Director of Nursing (DON), she confirmed that R19 was not afforded the right to formulate her choices for an Advance Directive. Review on [DATE] at 9:14 AM of the facility policy titled, Advance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain a homelike environment for one of two residents (Resident (R) R42) reviewed for environment. Specifically, R42 had food crumbs, paper trash, and other particles on the floor. This had the potential to affect all 47 residents residing in the facility. Findings Include: During initial tour of the facility on 01/31/22 at 12:43 PM, observation of food crumbs and paper trash were noted lying on the floor in R42's room. Observation on 02/01/22 at 8:54 AM , food crumbs and paper trash were observed on the floor in R42's room located in the same place as observed on the previous day. Observation on 02/02/22 at 8:59 AM, food crumbs and paper trash were observed on the floor in R42's room located in the same place as observed on the previous dates of 01/31/22 and 02/01/22. Observation on 02/02/22 at 8:59 AM, during a wound care observation with R42, it was noted the floor had a large amount of food crumbs and other non-identified dirt particles, a smashed brown food substance, a dried red liquid substance, gauze, and paper…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-03 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents (R) R30 and R42), who were given mental health diagnoses and were not provided a Pre-admission Screening and Resident Review (PASARR) level 2 evaluation to determine the need for individualized mental health treatment and support services. Specifically, R30 was admitted with diagnoses of depression and psychotic disorder and received antipsychotic medication with no PASARR level 2 referred. R42 was admitted with a diagnosis of dementia and was later given a diagnosis of schizophrenia disorder and was prescribed an antipsychotic medication with no PASARR level 2 referred. This failure placed the residents at risk for unmet care needs, unnecessary medication/s, and at risk for not receiving appropriate mental health treatment and support/services needed. This had the potential to affect all residents with a mental health diagnosis. Findings Include: Review of the Review of the Diagnostic Criteria for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-03 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement the comprehensive care plan interventions for two residents (Resident (R) 30 and 41) of five reviewed for psychotropic medication care plan/s. These failures had the potential to affect all residents prescribed psychotropic medications with target behaviors by increasing the potential for harm due to the facility failing to implement nonpharmacological methods that were identified on the care plan with the usage of unnecessary medications. Findings include: Review of the admission Record, located on the Face Sheet in the electronic medical record (EMR), indicated R41 was admitted to the facility on [DATE] with diagnoses including but not limited to; acute pulmonary edema, major depressive disorder, unspecified dementia, repeated falls, and anxiety disorder. Review of the EMR admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/14/22, revealed R41 was moderately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · D2022-02-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, interview and review of the facility's policy titled, Wound Care, and Handwashing/Hand Hygiene, the facility failed to ensure proper wound care for Resident (R)1 for 1 of 3 residents reviewed for Pressure Ulcers. Findings Include: The facility admitted R1 with diagnoses including but not limited to; pressure ulcer of left and right hip, repeated falls, difficulty walking and lack of coordination. Review on 2/2/22 at 12:05 PM of the medical record for R1 revealed a physician's order for wound care. The order reads: Clean the left and right buttocks and perineum with wound cleanser and pat dry. Apply collagen powder and calcium alginate to the wound bed and cover with a dry dressing and secure with tape. An observation on 2/2/22 at 12:10 PM of wound care for R1 went as follows: Registered Nurse (RN)1 and Licensed Practical Nurse (LPN)1 began preparing R1 for the wound care. RN1 applied gloves to her hands and removed the top cover from the resident and raised the bed for better access to R1's wounds. Using the same gloved hands, RN1 mixed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-03 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to ensure there was sufficient nursing staff available to respond to call lights and assist residents as needed for five of the 12 residents (Residents (R) R32, R10, R22, R29, R39) attending the Resident group and one of two residents reviewed for environment (R32). This failure has the potential to affect all residents who resided in the facility. The census was 43. Findings include: On 01/31/22 at 12:47 PM, R32 was observed eating while in bed. R32 was leaning to her right side while eating her food with her left hand. When asked if she was ok, R32 stated she was concerned about her position because she couldn't see her food. When asked if R32 had activated the call light to request for assistance in positioning, R32 stated she didn't know where the call light was. Further observation revealed after activating the call light it was approximately 15 minutes later, staff had not come to assist the R32. Observation of the nurse ' s station revealed no one was at the nurse's station at the time R32's call light was activated.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-03 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to respond to Resident (R)41 during a hallucination episode. Findings Include: An observation on 2/2/22 at 11:09 AM revealed R41 in the dining area having a hallucination episode for 20 minutes with little to no staff intervention or redirection attempts. Certified Nursing Assistant (CNA)1 was observed during this time period on their phone in close proximity to the resident. Further observation revealed Physical Therapist (PT) 2 redirect the resident and assist them to the therapy gym. An interview on 2/2/22 at 11:37 AM with CNA1 revealed that he heard the resident yelling, but didn't think to help with an intervention because he thought the therapy staff had it covered. Further interview confirmed that CNA1 was on the phone looking through messages during the time of R41's hallucination episode. A phone interview with the Resident Representative for R41 revealed ongoing concerns related to staffing and the quality of care R41 is currently receiving at the facility. An interview with the Director of Nursing (DON) on 2/3/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-03 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and review of the facility policy titled, Administering Medications, the facility failed to ensure medications were not touched for Resident (R)145 with bare hands during administration of medications on the 200 Hall for 4 medications out of 25 opportunities for error. The medication error rate was 16 percent. Findings Include: An observation on 2/1/22 at approximately 8:00 AM of medication administration for R145 revealed Licensed Practical Nurse (LPN)1 administering medications to R145. The LPN had 4 pills in a medicine cup and went to R145's room. She sat the cup of medications on a 3 drawer compartment outside R145's room door used for personal protective equipment. The LPN accidentally knocked over the cup of medications and picked them up one by one using her bare hands. The Director of Nursing was observing and asked the LPN if she had made sure that the cup now contained the total of 4 and the LPN stated it did. LPN1 then carried the pills into the resident's room and administered them to R145. During an interview on 2/1/22 at approximately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-02-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and review of the facility policy titled, Storage of Medications, the facility failed to ensure expired medications were removed from the 200 North Hall medication cart and not stored with medications for resident use on 1 of 4 medication carts observed . The facility further failed to ensure medication carts were locked on on the 100 North Hall and on the 200 South Hall for 2 of 4 medication carts observed. The facility additionally failed to ensure expired mediations were removed from the refrigerator in the 200 South Hall medication room for 1 of 4 medication rooms reviewed. Findings Include: An observation on 2/1/22 at 3:00 PM of the 200 North Hall medication cart revealed the medication, Oxycodone 1 tablet of 5 milligrams expired on 1/20/22. The medication Oxycodone 1 tablet of 10 milligrams expired on 1/20/22 and Oxycodone Hydrocel 1 tablet of Lot 21021 16616A KvK-Tech expired on 1/20/22. During an interview on 2/1/22 at 3:00 PM the Director of Nursing confirmed the expired medications and removed them from medications for resident use. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-02-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and review of the facility policy titled, Administering Medications, the facility failed to ensure medications were not touched for Resident (R)145 with bare hands during administration of medications on the 200 Hall for 4 medications out of 25 opportunities for error. Findings Include: An observation on 2/1/22 at approximately 8:00 AM of medication administration for R145 revealed Licensed Practical Nurse (LPN)1 administering medications to R145. The LPN had 4 pills in a medicine cup and went to R145's room. She sat the cup of medications on a 3 drawer compartment outside R145's room door used for personal protective equipment. The LPN accidentally knocked over the cup of medications and picked them up one by one using her bare hands. The Director of Nursing was observing and asked the LPN if she had made sure that the cup now contained the total of 4 and the LPN stated it did. LPN1 then carried the pills into the resident's room and administered them to R145. During an interview on 2/1/22 at approximately 8:15 AM with LPN1 and the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$16,153 in federal fines across 1 penalty.
- $16,153 — penalty dated 2025-05-22
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WELLMORE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/21/2015 |
| MAXWELL GROUP, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2025 |
| THOMPSON, BENJAMIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2022 |
| MACON, JONATHAN | Individual | ADP OF THE SNF | — | since 09/22/2025 |
| PAVLICK, CRYSTAL | Individual | ADP OF THE SNF | — | since 09/22/2025 |
CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $939K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in SC
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the South Carolina Medicaid page for homes that do.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 425412. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.